Texas features one of the largest trauma care systems in the country. But behind the emergency room doors lies a complex web of funding mechanisms, regional coordination, and public policy decisions. The Texas trauma care system, in short, is the safety net that keeps people alive after car crashes, falls, gunshots, and other critical emergencies. The Texas Legislature directly shapes many of these components. Thus, ensuring that the safety net is strong, well-funded, and responsive takes continuous legislative attention. This is especially true in a state as vast and diverse as Texas.
Below we describe the Texas Trauma Care System, its funding, and why the issue continues to recur on lawmakers’ agendas.
What Is the Texas Trauma Care System?
At its core, the trauma care system consists of a network of trauma hospitals, emergency medical services (EMS), air ambulances, and local providers that treat the most serious, life-threatening injuries. It is designed to provide fast, organized, and high-quality care when minutes make the difference between life and death.
Texas organizes this system across 22 defined geographic Trauma Service Area (TSA)—urban, rural, or somewhere in between. A Regional Advisory Council (RAC) leads each TSA. RACs serve as the backbone of the trauma care system because they connect all the pieces. They ensure coordination and effectiveness within their trauma care service area and among trauma care services areas. RACs are responsible for planning and coordination, system improvements, data collection, disaster preparedness and response, and education and training. that coordinates trauma care. These councils also help hospitals and EMS providers communicate, share resources, and make sure trauma patients get to the right facility with the right capabilities.
A hospital must be designated as a trauma facility (Level I to IV, with a Level One trauma center beibg the highest and a Level Four Trauma Center being the lowest) to officially participate. Think of it as a certification. If a hospital wants to be recognized as a trauma center, then it must meet strict criteria for trauma team staffing, equipment, training, response times, coordination, reporting, and tracking outcomes. Presently, Texas boasts 296 hospitals designated trauma centers in Texas.
- 22 Level I trauma centers
- 27 Level II trauma centers
- 62 Level III trauma centers
- 185 Level IV trauma centers
EMS serves as the critical first point of contact. They provide rapid assessment, stabilization, and transport of trauma patients to the most appropriate designated trauma center based on injury severity and regional protocols.
DSHS oversees the state’s trauma system to make sure patients get immediate, proper care after serious injuries. It sets rules for trauma hospitals, EMS providers, and RACs to follow, and checks that they meet safety and care standards. DSHS also collects data, supports training, and helps pay for trauma care to improve the system across Texas.
Why It Matters: Texas Has Big Trauma Center Challenges
Texas leads the nation in roadway mileage and traffic injuries and fatalities. In 2023, there were 18,800 people seriously injured in motor vehicle accidents and 4,291 deaths in Texas. Rural areas of the state accounted for 52 percent of the state’s traffic fatalities. According to the National Safety Council, the average economic cost per fatality is almost $2 million per incident.
Additionally, oilfield-related injuries in places like the Permian Basin, violent incidents in urban centers, and the sheer scale of rural Texas make trauma care not just a healthcare issue—but a public safety and transportation issue as well. In these settings, trauma care isn’t optional—it’s a critical infrastructure component. But as demand grows, especially in rural areas with hospital closures or thin EMS coverage, Texas must wrestle with how to keep this system operational and accessible to all Texans.
Legislative Role: Oversight, Funding, and Fixes
Funding the System: Account 5111
The Texas Legislature plays a central role in maintaining and improving the trauma care system. Here’s how:Much of the trauma care system’s funding comes from a dedicated fund created by the Legislature in 2003: the Designated Trauma Facility and Emergency Medical Services Account, also known as Account 5111.
This account collects revenue from traffic fines and court costs, including:
- Surcharges from the Driver Responsibility Program (now repealed, more on that below)
- Certain court fees for traffic offenses
- Criminal conviction surcharges related to alcohol or drugs
Originally, the idea was simple: use money from traffic violations to fund the hospitals and emergency services that respond to those crashes. It was a way to connect cause and effect—and free up General Revenue for other priorities.
Repeal of the Driver Responsibility Program (2019)
But the system hasn’t always worked as planned. Over the years, trauma funds were used to help balance the budget instead of going to directly support the trauma system.
A major shake-up came in 2019, when the Legislature repealed the controversial Driver Responsibility Program (DRP), which had been one of the main sources of revenue for trauma care. While widely seen as punitive and ineffective (often trapping low-income Texans in debt), its repeal left a funding hole.
To compensate, lawmakers redirected other criminal fines and court fees into Account 5111, but revenue levels dropped. Since then, the Legislature has faced repeated pressure from hospitals, EMS providers, and RACs to find more stable, long-term funding.
Trauma Care Funding Methodology
The Legislature allocates trauma funding through appropriations and by statute with certain percentages going to components of the trauma system: trauma facilities, EMS, RACs, and DSHS. 94 percent of the appropriated funding must go to reimburse uncompensated trauma care. The statute also allows for the funding intended for trauma facilities to be used to draw down additional federal funding through the Health and Human Services Commission (HHSC). This mechanism maximizes the funding available for uncompensated trauma care. The trade-off of the methodology is that smaller hospitals including rural hospitals do not get as much money because they are not eligible for the federal funding. This creates challenges in maintaining Level IV facilities across the state to serve rural patients.
The Legislature also allocates funding to RACs , EMS, and DSHS to support coordination of the trauma system, the immediate lifesaving care provided on scene, and the transport to a trauma care facility.
- Up to two percent of appropriated trauma funds go to RACs.
- Three percent of appropriated trauma funding goes to EMS providers to support their role in the trauma system.
- One percent of appropriated trauma funds are used by DSHS to administer the Texas trauma system.
The question remains as to whether there is sufficient funding to adequately support all components of the trauma system.
Key Challenges and Ongoing Legislative Issues
Several recurring topics appear on the legislative radar when it comes to trauma care:
• Rural Trauma Gaps
As rural hospitals close or reduce services, access to trauma care gets more uneven. Some parts of Texas are hundreds of miles from the nearest Level I or II trauma center. The Legislature is under growing pressure to fund telemedicine, support rural EMS providers, and expand the reach of RACs in underserved areas.
• Uncompensated Care
Many trauma patients are uninsured or underinsured. Hospitals must stabilize them regardless of ability to pay, as required by federal law (EMTALA). This leads to millions in uncompensated trauma care costs—especially for Level I and II facilities in border and urban regions. Lawmakers often hear calls to boost reimbursement or increase trauma funding to offset these costs. However, there is an inherent tension between the urban areas with the most trauma care and the rural areas with more limited access to care.
• Air Ambulance Regulation
Given the distances in Texas, air ambulances play a big role in the trauma system. However, their regulation is complicated—partly governed by federal aviation rules. Some stakeholders have pushed for more state-level control over pricing, service quality, and coordination with RACs.
• Workforce Shortages
Keeping qualified trauma surgeons, other physicians, nurses, and EMS professionals in Texas—especially in rural areas—is another priority. Lawmakers have considered various workforce incentives and training grants, often tied to medical schools or rural health initiatives.
A Real-World Example: Senate Bill 1018 (89th Legislature)
In 2025, the Texas Legislature passed Senate Bill 1018. The bill changes the percent distribution of state traffic fines to increase the amount of funding to trauma account 5111. The Texas Legislature made this change to stabilize the funding to the trauma system.
Final Thoughts: A System That Needs Constant Tending
Texas’ trauma care system is not something you set and forget. It requires ongoing investment, strategic oversight, and—frankly—a lot of legislative elbow grease. As funding mechanisms evolve and population growth stretches resources thinner, lawmakers will continue to grapple with how to keep the trauma safety net intact.
For Texans on the road, on the job, or at home, the next trip to the ER might depend on decisions made in a Capitol hearing room months—or even years—before. For that reason, the Legislature’s role in trauma care policy remains as urgent as the sirens behind the scenes.
Frequently Asked Questions About Texas Trauma Care Levels
What is trauma care and how is it different than trauma informed care?
Trauma care and trauma-informed care are different in what they focus on, where they happen, and how they are delivered. While trauma care addresses immediate bodily harm, trauma-informed care addresses the lasting effects of psychological trauma on a person’s well-being.
Trauma care deals with treating physical injuries caused by things like car crashes, falls, or violence. This type of care happens in designated trauma centers, which are special hospitals with the staff and equipment needed to handle emergencies and perform life-saving procedures. On the other hand, trauma-informed care focuses on the emotional and psychological effects of distressing events, such as abuse, neglect, or loss. It is used in places like hospitals, schools, and social service agencies to create safe, supportive environments that help people heal and avoid being emotionally harmed again.
What are the five levels of trauma care?
Trauma care in the U.S. is generally categorized into five levels (I–V), with Texas officially recognizing Levels I through IV. Each level reflects a hospital’s capabilities in treating trauma patients:
- Level I – Comprehensive trauma care, research, and education.
- Level II – Similar care as Level I but without the academic research requirement.
- Level III – Initial assessment, surgery, and stabilization of trauma patients.
- Level IV – Basic emergency care and stabilization before transfer.
- Level V – Recognized in some states, typically offers initial evaluation and referral (not officially designated in Texas).
What is a Level One trauma center?
A Level I trauma center provides the highest level of surgical care to trauma patients. It must have 24/7 in-house coverage by general surgeons and access to specialists like neurosurgeons, orthopedic surgeons, and more. These centers also lead in trauma research, education, and system leadership. In Texas, hospitals like Memorial Hermann in Houston and Dell Seton in Austin are examples of Level I centers.
What is a Level Two trauma center?
Level II centers provide comprehensive trauma care and may manage the majority of injured patients. While they meet many of the same standards as Level I centers, they are not required to engage in academic research or trauma-related residency programs. These centers serve as major regional hubs, especially in less urban parts of Texas.
What is a Level Three trauma center?
Level III trauma centers are equipped to assess, resuscitate, perform surgery, and stabilize trauma patients. They maintain 24-hour immediate coverage by emergency medicine physicians and have prompt access to surgeons and anesthesiologists. These facilities are vital in rural and semi-urban areas, serving as essential stabilizing points before patient transfers to higher-level centers.
What is a Level Four trauma center?
Level IV centers provide advanced trauma life support (ATLS) before patients are transferred to a higher-level facility. They offer initial evaluation, stabilization, and diagnostic services. These centers play a critical role in Texas’s vast rural areas, ensuring that timely trauma care begins as close to the injury site as possible.
What is meant by “trauma code”?
A “trauma code” is a designation used by emergency departments to quickly mobilize trauma teams for incoming patients with potentially life-threatening injuries. It triggers a coordinated, multidisciplinary response—often including surgeons, nurses, respiratory therapists, and radiologists—to improve outcomes during the “golden hour” of trauma care.
What is the role of the American College of Surgeons in trauma care?
The American College of Surgeons (ACS) helps make sure people with serious injuries get the best care possible. It does this by creating rules and programs that guide how trauma centers work, train doctors, and prevent injuries. The ACS also checks and approves trauma centers to make sure they meet high standards for treating injured patients. For more information, visit the American College of Surgeons site.